Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middleincome countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood.
Trang 1R E S E A R C H A R T I C L E Open Access
The power of practice: simulation training
improving the quality of neonatal
resuscitation skills in Bihar, India
Brennan Vail1* , Melissa C Morgan1,2,3, Hilary Spindler3, Amelia Christmas4, Susanna R Cohen5
and Dilys M Walker3,6,7
Abstract
Background: Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood
Methods: This study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India Further, it explores barriers to performance of key NR skills PRONTO training was conducted within CARE India’s AMANAT intervention, a maternal and child health quality improvement project Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training Performance in live deliveries was evaluated in real time using
a mobile-phone application Barriers were explored through semi-structured interviews with simulation facilitators Results: In total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01) No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps In 252 live deliveries,
identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23%
respectively (all p < 0.01) between weeks 1–3 and 4–8 Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills
Conclusion: PRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process
Keywords: Neonatal resuscitation, Bihar, India, Simulation Training, Barriers to Care
* Correspondence: brennan.vail@ucsf.edu
1 Department of Pediatrics, University of California San Francisco, 550 16th
Street, 4th Floor, Box 0110, San Francisco, CA 94158, USA
Full list of author information is available at the end of the article
© The Author(s) 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver
Trang 2In 2016, 43% of deaths in children under age five
globally occurred during the neonatal period [1] In
India, neonatal deaths accounted for 56% under-five
deaths [1] and over half of these deaths occurred in only
four states: Bihar, Uttar Pradesh, Madhya Pradesh, and
Rajasthan [2] Bihar is a state in eastern India with the
highest rural birth rate in the country [3] and the highest
multidimensional poverty index in all of South Asia [4]
Nearly one-third of neonatal deaths in Bihar are due to
intrapartum related events [5], and yet providers are not
adequately trained to perform basic neonatal
resuscita-tion (NR) [6, 7] Approximately 10% of neonates require
tactile stimulation to transition at the time of birth and
3–6% require positive pressure ventilation (PPV) [8] It
is estimated that the effective provision of basic NR could
save over 60,000 infants in India alone annually [9]
Although, there are many NR training programs in
low- and middle-income countries (LMICs) [10], very
few studies have evaluated the impact of such programs
on the quality of clinical skills amongst providers with
limited formal medical education in rural community
settings One small study evaluating the skills of
com-munity health workers in Bangladesh found
improve-ment in initial resuscitation practices (drying, tactile
stimulation), neck extension, and mouth-to-mouth
ven-tilation with training, though no statistical analysis was
provided [11] More studies have focused on providers
at referral hospitals [12–18] Results from these studies
are variable, with some demonstrating improvements
in initial resuscitation [12, 15, 17, 18] and PPV skills
[12–17], while others showed no change in initial
resuscitation skills [14] or time to initiation of PPV
[12, 15] Several studies assessed skills at one time
point and thus could not sufficiently determine the
impact of training [19–23] Others reported only a
composite evaluation of skills [24–28], which is less
relevant for NR, where outcomes depend on adequate
performance of initial steps before proceeding to
more complex ones
This study offers a unique large-scale evaluation of an
eight week, in-situ NR training program developed by
PRONTO International [29] and implemented in rural
primary health centers (PHCs) across Bihar with
pro-viders with limited formal medical education
PRONTO training was conducted within a larger
ma-ternal and child health quality improvement project
called Apatkaleen Matritva evam Navjat Tatparta
(AMANAT) [30–32] The specific objectives of this
study were 1) to evaluate the impact of PRONTO
training on the quality of NR skills in simulated
re-suscitations; 2) to evaluate the impact of PRONTO
training on performance in live deliveries requiring
resuscitation of a non-vigorous infant; and 3) to explore
obstacles to performance of specific evidence-based prac-tices (EBP) in NR in Bihar
Methods Study design and setting
This study employed a mixed methods approach to evaluate the impact of PRONTO training on the quality
of NR skills Quantitative methods were used for the first two objectives and qualitative methods were used for the third objective The portion of PRONTO simula-tion training evaluated in this manuscript was conducted
at PHCs, where the majority of labor and delivery care
in Bihar is provided Each PHC serves a predominately rural population of ~ 190,000 individuals (number based
on monitoring and evaluation data from CARE India [30]) PHCs provide largely preventative health care with limited curative services [33] The vast majority of ob-stetric and neonatal care at PHCs is provided by nurses with an Auxiliary Nurse Midwife (ANM) or General Nursing and Midwifery (GNM) qualification, which re-quire 2 and 3.5 years of training after completion of sec-ondary school, respectively [34] PHCs frequently face staffing shortages, often having only one nurse on duty
in the labor room at any given time [33] PHCs are not staffed with specialists, including pediatricians [33], and,
in general, doctors are unavailable to assist in the labor room Caesarian sections and instrumented deliveries are only performed at higher levels of care and thus require referral out of PHCs [33]
AMANAT and PRONTO interventions
AMANAT is multi-faceted quality improvement project, implemented by CARE India [30] in collaboration with the Government of Bihar, which seeks to improve mater-nal and child health outcomes in the state using a men-torship model of education [30–32] AMANAT mentors are nurses with a Bachelor’s degree in nursing recruited from across India Mentees are ANMs and GNMs employed at PHCs
PRONTO International training consists of in-situ sim-ulations of a variety of neonatal and obstetric emergencies, which are supplemented by teamwork and communica-tion activities, skills stacommunica-tions, and case-based learning [29] Within AMANAT, PRONTO was responsible for training mentors to teach mentees emergency obstetric and neo-natal care Doctors were not included in the PRONTO training at PHCs as they were not part of the larger AMA-NAT program at PHCs and were infrequently involved in labor and delivery care in these facilities Using a train-the-trainer model, PRONTO provided six days of training for mentors on simulation facilitation, team build-ing, communication skills, and debriefing skills before mentoring began, and a four-day refresher training three months into the mentoring period Over each 8-month
Trang 3phase, mentor pairs rotated between four PHCs, spending
one week per month at each PHC conducting simulations
On average, seven NR simulations were conducted at each
PHC over the 8 month training cycle
In the PRONTO curriculum, normal spontaneous
vaginal delivery (NSVD) simulations were introduced in
week 2 and NR and postpartum hemorrhage (PPH)
simulations were introduced in week 3 of training
Not-ably, bedside mentoring often began earlier, as mentors
attended live deliveries during teaching hours with
men-tees to provide real-time instruction on any
complica-tions that arose Formal assessment simulacomplica-tions were
conducted for NSVD, PPH, and NR at weeks 4 and 8 of
training Pre-training assessments were not conducted,
providing mentees time to adjust to simulation prior
to being evaluated NR simulations were conducted
with the NeoNatalie™ [35] mannequin in situ in the
labor rooms where mentees worked All simulations
were video-recorded to enable video-assisted debriefing as
well as for programmatic evaluation
Study population
ANMs/GNMs with labor room duties and interest in the
mentoring program were selected for participation as
mentees in AMANAT and PRONTO training This
analysis evaluates the clinical NR skills of mentees in
both real and simulated deliveries in phases 2 and 3 of
AMANAT mentoring conducted between September
2015 and July 2016 During this period, approximately
88% of mentees were ANMs and 12% were GNMs
Interview participants were mentors who served as
simulation facilitators Twenty mentors, one from each
phase 4 mentor pair, were selected for interviews in
January 2017 based on the following criteria: 1) mentor
was currently employed by AMANAT at the time of
interview, and 2) mentor had worked in ≥2 phases of
AMANAT (equivalent to 16 months in 8 different
PHCs) Two interviewees were unable to participate due
to illness and personal travel
Study procedures
Mentee performance in simulated resuscitations
Evaluation of the quality of mentees’ NR skills in
simu-lated resuscitations was based on video-recorded
assess-ment simulations from weeks 4 and 8 of training At
each PHC, mentees were selected by random lottery to
participate in the NR assessment simulation for a given
week Assessments were announced but the lottery was
conducted immediately prior to simulations The
simu-lated scenario began with a neonate found apneic while
breastfeeding 15 min after birth, progressing to require
suctioning, stimulation, and PPV This simulation was
chosen by mentors in place of a simulation beginning
with a birth as it involved less set up and was thus easier
to facilitate in high volume PHCs Additionally, it allowed mentees to focus only on NR during the assess-ment rather than progressing from NSVD manageassess-ment
to NR Assessment videos were transferred to encrypted USB drives and transported to Patna, the capital of Bihar, where they were uploaded to an encrypted server and transferred to University of California San Francisco (UCSF) Videos were then coded by one of the lead investigators with pediatric clinical experience for pre-defined NR quality indicators selected by a team of clinical and simulation experts at UCSF and the Univer-sity of Utah The coder was blinded to time of assess-ment (week 4 vs 8 of training) After the completion of coding, indicators least likely to be subject to bias due to simulation artifact were selected for inclusion in the analysis Variable definitions are provided in Table1
Mentee performance in live resuscitations
Mentors attended births occurring in the PHCs during daytime working hours from Monday through Saturday Mentors were asked to assess mentees’ skills immedi-ately after observed live deliveries using a smart phone application based on the OpenDataKit platform [36] The application asked mentors to subjectively evaluate specific NR skills by indicating if the skill ‘went well’ or
‘needed improvement.’ This manuscript only evaluates mentees’ performance during live deliveries in which the neonate was non-vigorous
Table 1 Definition of key variables
Binary variables Stimulation Clinically adequate stimulation performed prior
to initiation of PPV Suction Suction performed prior to initiation of PPV Neck extension Neck extended in the proper sniffing position
using towel roll or head tilt PPV with chest rise PPV with three consecutive breaths with visible
chest rise PPV rate 40 –60
breaths/minute
PPV delivered at a rate of 40 –60 breaths per minute
Heart rate assessed Heart rate assessed at any point during the
resuscitation Time-based variables
Mentee hands on neonate
Time elapsed between the mother calling for help and the nurse mentee placing hands on the neonate to begin the clinical evaluation Neonate placed on
warmer
Time elapsed between the mother calling for help and the neonate being placed on the warmer to begin the resuscitation Initiation of PPV Time elapsed between the mother calling for
help and the initiation of PPV PPV with chest rise Time elapsed between the mother calling for
help and the third consecutive breath of PPV with visible chest rise
PPV positive pressure ventilation
Trang 4Barriers to evidence-based NR practices
Mentors were interviewed about the barriers to EBP in
NR that they had observed mentees facing in PHCs
Study procedures for the qualitative portion of this
manuscript have been described in detail in a separate
manuscript [37] In brief, a semi-structured interview
guide was developed and piloted with a former
AMA-NAT mentor A portion of the interview guide asked
mentors about each of the following skills before and
after training: warming/drying/stimulating, measuring
heart and respiratory rates, achieving chest rise during
PPV, and performing the resuscitation with adequate
ur-gency The interview guide allowed the interviewer the
flexibility to ask open-ended questions regarding barriers
to these skills and to further explore emerging themes
One-on-one interviews were conducted in English by
one of the lead investigators in a private room at PHCs
If the interview was conducted outside of business hours
or private space was unavailable, the interview was
con-ducted in a private location near the PHC All
inter-viewees were fluent in English Interviews were observed
by a local Hindi-speaking member of the PRONTO
team in case minor phrase translations were required
Interview duration ranged from 45 to 75 min
After 18 interviews, the interviewer concluded data
saturation had been reached as no new barriers to care
were being identified However, this manuscript only
presents barriers specifically linked by mentors to one of
the skills evaluated in simulated or live resuscitations in
an attempt to provide context for quantitative trends
Thus, this manuscript is not an exhaustive exploration
of barriers to care, and other barriers that were not
explicitly linked to a specific resuscitation skill are
explored in a separate manuscript [37]
Analysis
All quantitative analyses were conducted using IBM
SPSS Statistics 23 [38]
Mentee performance in simulated resuscitations
Assessment simulations from weeks 4 and 8 of training
were paired by PHC Simulation videos that were
cor-rupt or could not be paired were discarded Simulations
where the mentor stepped in to assist mentees or where
the clinical scenario deviated from the assessment
sce-nario were also discarded The percentage of simulations
in which mentees correctly completed key NR tasks,
meeting quality indicators, at weeks 4 and 8 of training
was compared using McNemar’s Test for paired
propor-tions The median time to mentee completion of key NR
tasks at weeks 4 and 8 was compared using the
Wilcoxon Signed Rank Test due to violation of the
normality assumption of parametric methods
Mentee performance in live resuscitations
The percentage of live deliveries in which mentors felt mentees adequately performed key NR skills was graphed by week of training Additionally, the percent-age of deliveries in which NR skills‘went well’ in weeks 1–3 was compared to weeks 4–8 using the Pearson Chi-Squared Test Week 3 was chosen as the cut-off because NR simulations were introduced into the PRONTO curriculum at that time If the expected cell count assumption was violated, a Fisher’s Exact Test was substituted
Barriers to evidence-based NR practices
Audio-recorded interviews were transcribed and analyzed by the interviewer Qualitative analysis was conducted using the thematic content approach [39,40], which included 1) data familiarization, 2) identifying codes and then themes, 3) developing a coding scheme and applying it to the data, and 4) refining and organiz-ing codes consistent with the Braun and Clarke approach to thematic analysis [41] Two interviews (10%) were selected at random for double coding to en-sure consistency in identification of key themes
Results Mentee performance in simulated resuscitations
A total of 1342 mentees at 160 PHCs participated in phases 2 and 3 of AMANAT/ PRONTO training A randomly selected subset of these mentees was evaluated
in 279 NR assessment simulations, which were video-recorded and coded for quality indicators This analysis includes 226 (81%) assessment videos, or 113 PHC-matched week 4 and 8 video pairs
From week 4 to 8 of training, there was a 13.5 percen-tage-point increase in proper neck extension (p = 0.01), a 19.0 percentage-point increase in PPV with visible chest rise (p < 0.01), and an 11.6 percentage-point increase in assessment of heart rate during resuscitations (p < 0.01) There was no statistically significant change between weeks 4 and 8 in adequate stimulation, suction, or deliv-ery of PPV with the proper rate (Table2) Additionally, there was no statistically significant change in median time to completion of key NR tasks (Table3)
Mentee performance in live resuscitations
Mentee performance was evaluated in a total of 3195 live deliveries in phases 2 and 3 Amongst these, 252 (8%) were complicated by birth of a non-vigorous neonate From early to later weeks of training, the per-centage of deliveries in which mentees’ identification of non-vigorous neonates, suctioning, and PPV ‘went well’ increased by 20.7, 25.4, and 22.7 percentage-points respectively (allp < 0.01) The percentage of deliveries in which mentors felt mentees performed adequate
Trang 5stimulation was high at baseline (94%) and did not
change significantly (Table 4) The week-wise trend in
these four variables is illustrated in Fig.1
Barriers to evidence-based NR practices
High level themes and illustrative quotations of barriers to
1) initial resuscitation, 2) measuring heart and respiratory
rates, 3) achieving chest rise during PPV, and 4)
perform-ing the resuscitation with adequate urgency are
summa-rized in Table5
Initial resuscitation
Prior to training, mentors explained mentees did not
understand the clinical significance of the initial steps of
resuscitation (warming, drying, stimulating, and suction)
and did not know how to properly perform these steps
Rather, they performed traditional practices including
holding the neonate upside down, over stimulating, and
massaging the chest Additionally, equipment issues,
including the availability of clean, dry cloths precluded
effective initial resuscitations
After training, mentors felt that mentees knew how to
perform warm/dry/stim in an evidence-based manner
However, mentors reported that mentees often forgot to
perform these initial resuscitation steps in a perceived
rush to begin ventilation On the other hand, mentors
felt mentees still did not understand the clinical indica-tions for suctioning and were too quick to jump to this step Supply issues remained a barrier to initial resuscita-tion after training Mentors explained that equipment, including mucus extractors, was often unavailable or dis-organized and thus inaccessible when urgently needed
Measurement of heart and respiratory rates
Mentors explained that prior to training, mentees did not know how to measure vital signs, were inaccurate in their counting, or were unaware of normal parameters and their clinical significance for neonates This was likely connected to the belief, prior to training, that the management of non-vigorous neonates was the responsi-bility of doctors Mentors also explained that mentees’ goal in resuscitations was simply to make the baby cry,
so vital signs were frequently overlooked
This goal remained true after training Mentors reported that mentees frequently forgot to check vital signs because they were too focused on simply mak-ing the neonate cry Nevertheless, mentors felt that mentees understood the significance of vital signs after training However, they still could not measure them accurately, often because they did not have or could not read a clock
Table 2 Percent of simulations in which mentees correctly performed key NR skills at weeks 4 and 8 of training (N = 113 matched pairs)
n (%)b
NR Neonatal resuscitation, PPV Positive pressure ventilation
a
N = total number of PHC-matched week 4 and 8 simulation pairs in which key NR skill could be evaluated
b
n = number of week 4 and 8 simulations in which key NR skill was completed % = percent of week 4 and 8 simulations in which key NR skill was completed
c
Percentage-point difference in completion of key NR skill from week 4 to 8 of training
d
McNemar ’s Test of paired proportions
Table 3 Time to mentee completion of key NR skills in simulation at weeks 4 and 8 of training (N = 113 matched pairs)
secondsc
P-value d Median (IQR) b
NR Neonatal resuscitation, PPV Positive pressure ventilation, IQR Inter-quartile range
a
N = total number of PHC-matched week 4 and 8 simulation pairs in which key NR skill could be evaluated
b
Median time in seconds to completion of key NR skill (inter-quartile range)
c
Difference in median number of seconds to completion of key NR skill from week 4 to 8 of training
d
Trang 6PPV with chest rise
Mentors explained that knowledge of all aspects of PPV,
including clinical significance, mask selection, rate of
de-livery, and assessment of effectiveness was lacking before
training If ventilation was provided, it was often given
mouth-to-mouth or by using a self-inflating bag on the
mother’s abdomen without knowledge of proper
tech-nique Similar to the measurement of vital signs,
men-tors explained that some mentees believed that docmen-tors
were responsible for managing non-vigorous neonates
prior to training, which meant they did not initiate
ven-tilation themselves
After training, mentors felt mentees had accepted the
responsibility of providing PPV, but that they continued
to have difficulty with mask seal, rhythm, and
assess-ment of PPV effectiveness Approximately two-thirds of
mentors reported observing continued difficulty with
neck extension after training, while one-third of mentors
felt mentees had mastered this skill Additionally,
men-tors reported mentees did not know when to stop PPV
for reassessment because mentees did not have or could not read a clock The availability of ventilation bags and different mask sizes, particularly preterm masks, was identified as a barrier after training likely persistent from before training but more frequently identified after PPV became an accepted duty of mentees Finally, one mentor felt the traditional belief that oxygen was im-portant in addressing respiratory distress was a barrier
to performing PPV with self-inflating bags with no oxygen source after training
Urgency
Mentors explained that mentees did not understand the concept of the golden minute or the significance of achieving effective ventilation within that timeframe prior to training Additionally, they did not know how to accurately identify non-vigorous neonates requiring resuscitation Further, mentors explained the traditional practice in Bihar was to patiently wait for neonates to cry, which commonly delayed resuscitations Other
Table 4 Percent of live deliveries in which mentees successfully completed key NR Skills in the early versus later weeks of training (N = 252)
changec
P-value
N a
n (%) b Identification of non-vigorous infant 66 32 (48.5) 156 108 (69.2) 20.7 < 0.01d
NR Neonatal resuscitation, PPV Positive pressure ventilation
a
N = number of live deliveries in which performance of NR skill was required and recorded
b
n = number of live deliveries in which NR skill was successfully completed; % = percent of live deliveries in which NR skill was successfully completed
c
Difference in percent of live deliveries in which NR skill was completed from early to late weeks of training
d
Pearson Chi-Squared Test
e
Fisher ’s Exact Test
Fig 1 Trend in the Percent of Live Deliveries in which Mentees Successfully Completed Key NR Skills by Week of Training
Trang 7Table 5 Barriers to Evidence-Based Practices in Neonatal Resuscitation Before and After Training
Initial resuscitation
Knowledge “They were not knowing ok there is a need to
stimulate and they were not knowing ok why they need to dry the baby ”
“So much suctioning is there… with the help of drying
or stimulating the baby can be saved, but in spite of that they used to go for suctioning … like if baby didn’t cry means ok get … sucker, get sucker.”
Traditional Practices “They’ll hold the baby upside down, they will shake the
baby here and there, they ’ll beat the baby… but… the proper stimulation they were not aware [that] they should rub the baby back or they should flick [the feet] ”
Equipment “They used to dry the baby but… not with a clean or
dry cloth ” “Baby was [asphyxiated with] thick meconium…suction, all the thing[s] [were] not available and we
don ’t know where they are.”
Focus on Later Management “[Mentees] think that if the baby is not crying, they
have to take [the baby] immediately to the warmer,
so they forget the stimulation part ” Measurement of heart and respiratory rates
Knowledge “Actually before… [mentees] were not knowing ok
heart rate and respiration[s] are two different things … then we started teaching them anatomy Respiration-this is the work of lungs … and heart rate- this is the work of heart ”
sake they see … or they don’t see it properly… the counting goes here and there They don ’t get it accurately ”
heart rate because … watch is not available.”
Focus on Later Management “The goal is the baby should cry [Mentees] don’t see
for the respiration rate or for the heart rate, they just see that the baby cries … keep on stimulating so that the baby cries ”
“Until [mentees] see the baby [cry], they will give bag and mask, bag and mask In between … check heart rate, respiratory rate, they were not doing ”
Role of MD “[Mentees] said… ‘what’s heart rate? How do we check
that? That ’s doctor’s thing, they do that with the stethoscope ’”
PPV with chest rise
Knowledge “They were not knowing about the PPV If any of the
[mentees] knew, she was not knowing the correct rhythm … how much time you need to do, how you need to She only knew ok we need to do ” Skill “[Mentees] just pump [the Ambu bag]… according to
the baby[ ‘s] size they don’t use the [correct] mask.
Whatever mask they get, they will connect that and they will pump it ”
“[Mask] seal is not good for most of the time… and the rhythm also Some of the mentees, they forget the [ventilation] rhythm also ”
Traditional Practices “Before… in some facilities [mentees] were giving
mouth to mouth ventilation … that time they didn’t know how to use bag and mask ventilation ”
“PPV they are doing but they have more belief in oxygen If we will put the oxygen … baby will be crying they believe only ”
have only one number mask, so it is not as effective, because in preterm baby we can ’t use the big one.” Role of MD “Before training [mentees] were not doing [PPV]… they
didn ’t know how to use bag and mask ventilation They only know … we can’t use, doctor has to do.”
Urgency
Knowledge “Actually they are not aware what is the effect [of
delay] Until we … know what is the effect, we will not take precaution ”
“[Mentees] can’t… understand when [the neonates] need resuscitation or not Sometimes they identify very well but … sometime[s] they waiting for… crying… It’s not proper timing ”
Trang 8delays were created by slow cord clamping and
perform-ance of the initial NR steps Finally, mentors described
mentees’ focus on maternal management as a barrier to
timely NR prior to training
After training, mentors explained mentees were better
at identifying non-vigorous neonates and knew about
the golden minute; however, some mentors expressed
concern some mentees still did not truly understand its
clinical significance Additionally, mentors explained
mentees could not read a clock to facilitate timely
resus-citations Regarding skills, mentors explained mentees’
inefficiencies in initial resuscitation and cord cutting
continued to delay resuscitations after training One
mentor felt that mentees spent too much time trying to
seal the mask Overall, mentors felt more practice
per-forming NR with proper timing was necessary Other
frequently mentioned barriers to urgency that were likely
persistent from before training were the traditional
practice of patiently waiting for the infant to cry, long
distances between labor rooms and the newborn care
corners (NBCCs), insufficient staffing, and issues with
supply availability, functionality, and organization
Discussion
PRONTO International’s NR simulation training,
imple-mented within the AMANAT quality improvement
ini-tiative, had a positive impact on key NR skills amongst
ANM/GNM mentees working in rural PHCs across
Bihar Nevertheless, there is room for continued
im-provement in nearly all NR skills, likely due to the need
for additional training as well as significant barriers that
go beyond the scope of clinical skills training For each
of the key skills evaluated in this manuscript initial resuscitation, assessment of vital signs, performance of PPV, and urgency in resuscitations we present a trian-gulated discussion of simulation data, live delivery data, and barriers to care identified by mentors in qualitative interviews to facilitate a more nuanced understanding of the positive impacts of PRONTO training and areas for improvement
Mentees’ performance of the initial NR steps, includ-ing warminclud-ing, dryinclud-ing, stimulatinclud-ing, and suctioninclud-ing, was variable This is consistent with previously published studies [12, 14] In interviews, mentors suggested that knowledge of EBPs increased with training However, there was no significant change in the percentage of sim-ulated NR scenarios in which mentees provided clinic-ally adequate stimulation prior to PPV from week 4 to 8
of training In observed live deliveries, there was simi-larly no significant change in stimulation between the early and later weeks of training; although, the rate of stimulation was high at baseline This knowledge-skill gap may be explained by mentors’ observation that men-tees frequently forgot initial NR steps in a perceived rush
to start PPV Moreover, the fact that the simulated sce-nario did not begin with a birth may have also contrib-uted to mentees’ relative failure to perform initial steps
in simulation compared to live deliveries Regarding suctioning, there was significant improvement in live deliveries, but not in simulated resuscitations Despite this improvement in live deliveries, about a quarter of live-born neonates deemed to require suctioning did not
Table 5 Barriers to Evidence-Based Practices in Neonatal Resuscitation Before and After Training (Continued)
Skill “To cut the cord, to take the baby to the NBCC, and to
start [the] resuscitation, it will take more than 5 min they were telling ”
“It will take time, especially drying the baby, wiping it, stimulating it, clamping … the cords.”
Traditional Practices “Because their old practice is like they… will wait,
they ’ll tell, ‘Baby will cry now, sister this is normal baby will cry now ’”
“They are thinking it might be crying… they are waiting for some time But when we are there we are telling them not crying so go fast! ”
clamping or … they search for suctioning, for mucus extractor … availability is not there in the PHC, so they
go outside to get ”
to labor room is NBCC, so that takes [mentees] more than a minute to take the baby from labor room to NBCC ”
Maternal Management “For one to two to three minutes [mentees] will wait…
because [until] the placenta is removed, they will concentrate on that Ok, the placenta is removed, after that they see, ok, baby is not crying Then they will start with the Ambu ”
will be taking care of the mother and then baby is not crying ”
PPV Positive pressure ventilation, PHC Primary health center, NBCC Newborn care corner
Trang 9receive it during week 8 of training, perhaps due to the
supply issues highlighted by mentors
Assessment of vital signs, including heart rate and
respiratory rate, was evaluated only in simulated
resusci-tations A significant improvement was observed from
week 4 to 8 of training Mentors explained that vital
signs were often not assessed before training due to
in-adequate knowledge and a prevalent belief that NR was
the doctor’s responsibility This suggests the observed
change in simulation data, which did not include a true
pre-training measurement, may underestimate the
im-pact of training on this skill Notably, while simulation
data captured whether or not mentees checked heart
rate, it did not assess the accuracy of heart rate
measure-ments Mentors explained in interviews that mentees
have difficulty reading a clock, suggesting this may be an
area for future improvement This will likely require
innovative solutions to help providers identify normal
versus abnormal vital signs without the need to count
precise rates
Proper delivery of PPV is the chief focus of many NR
trainings A significant improvement in PPV skills was
observed in both simulated and live resuscitations
fol-lowing PRONTO training Previous studies have
simi-larly reported improvement in PPV skills post-training
[12–17] During week 8, mentees achieved chest rise in
85 and 65% of simulated and live resuscitations,
respect-ively Other studies report comparable [12, 15] or lower
rates of effective PPV [14, 16] In interviews, mentors
explained mentees continued to struggle with mask seal,
rhythm, and real time assessment of PPV effectiveness
These observations are supported by the simulation
data, which demonstrated no change in the use of the
proper rate of PPV following training Although
inter-viewees disagreed about mentees’ ability to perform
proper neck extension, a significant improvement in this
skill was observed in simulations from week 4 to 8
Mentors felt the persistent PPV knowledge-skill gap was
due to insufficient practice as well as lack of availability
of functional supplies in PHCs The need for more
prac-tice with longer trainings is not an unfamiliar challenge
amongst NR programs in LMICs [42] and the PRONTO
training is unique in that it was conducted over
8 months Nonetheless, given the departure PPV
repre-sents from traditional practices in Bihar, interviewees felt
even this duration of training was insufficient
Urgency is another key area for improvement No
sig-nificant change was observed in the time to completion
of key NR tasks in simulations In fact, the median time
to effective chest rise trended upward non-significantly
from week 4 to 8 of training Other studies have
simi-larly reported both increased and unchanged durations
of time to PPV initiation [12, 15] Nonetheless, mentors
described a perceived rush to start ventilation after
training that negatively impacted initial resuscitation measures The discrepancy between the perceived urgency and true time to completion of key tasks may
be related to barriers such as inability to read a clock, distance between labor rooms and NBCCs, and both supply and human resources shortages Other barriers to urgency identified by interviewees included poor under-standing of the true significance of the golden minute and continued performance of traditional clinical prac-tices such as waiting indefinitely for the infant to cry Timely identification of non-vigorous neonates in live deliveries improved significantly; however, mentees still failed to identify nearly a quarter of live-born neonates deemed non-vigorous by mentors at the end of training These results have informed the next iteration of the PRONTO curriculum, which will include greater em-phasis on quick identification of non-vigorous neonates, beginning resuscitations with appropriate initial resusci-tation measures, recognition of vital sign abnormalities without counting specific rates, and timely initiation of effective PPV Nevertheless, this study has several limita-tions Foremost, due to the unreliable birth registry sys-tem in Bihar, there are no reliable clinical outcome data
on which to base the impact of this training program For this reason, we used simulation data as a proxy The simulation data lack a true pre-training measure-ment, which may cause an underestimation of the true impact of training Nonetheless, this was a conscious choice to allow mentees to adapt to simulation proce-dures prior to evaluation given their lack of familiarity with this method of learning [42] The assessment simu-lation was also not changed between week 4 and 8 However, this is unlikely to have led to an overesti-mation of the impact of training given the aim of this study was to assess the quality of basic NR skills, which should follow an algorithm that is relatively independent
of the clinical scenario in uncomplicated resuscitations Additionally, simulation data represent the performance
of only a subset of mentees who participated in the NR assessment simulations at week 4 and 8 of training However, as the selection process was random, the im-pact of selection bias is likely minimal Finally, this data
is based on a single video assessor, which could have introduced interpretation bias However, the potential for this bias was minimized by blinding the assessor to week of training and by choosing an assessor who was independent from training implementation
The live birth data represent a convenience sample and could be biased, as data were collected by mentors who were not blind to week of training and who had somewhat limited clinical training themselves, as most were early in their nursing career Further, live delivery data provide only a binary and subjective assessment of whether key NR steps went well or not Nevertheless,
Trang 10these data provide the only assessment of performance
in live deliveries, as medical record keeping is
inconsist-ent The investigators felt that a more rigorous
assess-ment of resuscitations in real time would impact clinical
care or preclude data collection given the high delivery
volume at PHCs
Qualitative interview data could be influenced by
desire of mentors to please the interviewer as well as by
any preconceptions mentors may have had about
intra-partum or postnatal care in Bihar We attempted to
mitigate these potential biases by clearly stating during
the consent process that interviews were not a
perform-ance evaluation and by selecting interviewees with at
least 16 months of mentoring experience in PHCs
Finally, not all qualitative interview data regarding
barriers to care is included in this manuscript Rather,
logistical, cultural, and structural barriers to immediate
neonatal care and NR are more fully explored in a
separ-ate manuscript [37] and this manuscript only presents
barriers explicitly linked by mentors to specific NR skills
assessed in simulated and live resuscitations
Conclusion
PRONTO simulation training conducted within the
AMANAT intervention had a positive impact on
know-ledge and the use of evidence-based NR practices amongst
numerous ANMs/GNMs working in rural PHCs
through-out Bihar Nevertheless there is a need for ongoing
improvement, which will require addressing many barriers
to care that extend beyond the scope of clinical skills
training Data triangulation, incorporating both
quantita-tive and qualitaquantita-tive methodologies, offers a powerful tool
for guiding this process in settings such as Bihar where
clinical outcome data are unreliable, yet the need for
im-provement in neonatal care is great
Abbreviations
ANM: Auxiliary nurse midwife; EBP: Evidence-based practices; GNM: General
nursing and midwifery; IQR: Inter-quartile range; LMIC: Low- and
middle-income countries; NBCC: Newborn care corner; NR: Neonatal resuscitation;
NSVD: Normal spontaneous vaginal delivery; PHC: Primary health center;
PPH: Postpartum hemorrhage; PPV: Positive pressure ventilation;
UCSF: University of California San Francisco
Acknowledgements
The authors would like to thank the entire CARE India team for their support
in facilitating PRONTO International simulation training as part of the
AMANAT program throughout Bihar We would also like to express our
sincere appreciation for all phase 2-4 mentors for their commitment to
teaching and their willingness to participate in qualitative interviews Thank
you also to the phase 2-4 participates for their commitment to the training
and willingness to learn Special thanks to Rebecka Thanaki, Renu Sharma,
and Praicey Thomas for their help in arranging and facilitating qualitative
interviews Lastly, thank you to the entire PRONTO International team for
their tireless work throughout implementation and evaluation of the
training program.
Funding This study was funded by the Bill and Melinda Gates Foundation The funding body had no role in the design of the study; the collection, analysis, and interpretation of data; or in writing the manuscript.
Availability of data and materials Data are not publicly available at this time as analyses are ongoing Interview transcripts are not publically available in an effort to ensure confidentiality for all interviewees Data and portions of the transcripts or interview guide may be made available on reasonable request to the corresponding author Authors ’ contributions
BV designed data collection tools, coded all simulation videos, conducted all interviews, performed qualitative and quantitative data analysis, and drafted and revised the manuscript MM provided clinical expertise and made substantial contributions to the design of data collection tools, data analysis, and manuscript revision HS was also involved in study design and critical revision of the manuscript AC was involved in PRONTO curriculum design, supervision of PRONTO training, provided expert local opinion for qualitative analysis, and critically revised the manuscript SC was involved in PRONTO curriculum design, study design, and made significant contributions during manuscript revision DW is the principal investigator for the evaluation of PRONTO in Bihar and made significant contributions to all aspects of study design and manuscript preparation All authors have approved this manuscript for submission.
Ethics approval and consent to participate Mentees provided written informed consent for the use of the simulation and live delivery data in an aggregated analysis Mentors provided written informed consent to be interviewed and to audio-record interviews Ethical approval was granted from the Committee on Human Research at UCSF (14 –15,446) and the Institutional Committee for Ethics and Review of the Indian Institute of Health Management Research.
Consent for publication Not applicable.
Competing interests
DW and SC are founding members of PRONTO International and sit on its board of directors None of the other authors have any conflicts of interest
to declare.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Author details
1 Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94158, USA.2Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
3 Institute for Global Health Sciences, University of California San Francisco,
550 16th Street, San Francisco, CA 94158, USA.4PRONTO International, State RMNCH+A Unit, C-16 Krishi Nagar, A.G Colony, Patna, Bihar 80002, India 5
College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT
84112, USA 6 Department of Obstetrics and Gynecology and Reproductive Services, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA 7 PRONTO International, 1820 E Thomas Street APT
16, Seattle, WA 98112, USA.
Received: 31 March 2018 Accepted: 15 August 2018
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